Provider Demographics
NPI:1194204321
Name:MANRIQUE, ANTONIO AUGUSTO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:AUGUSTO
Last Name:MANRIQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:MANRIQUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1104 NE 98TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2508
Mailing Address - Country:US
Mailing Address - Phone:786-624-9481
Mailing Address - Fax:
Practice Address - Street 1:500 N HIATUS RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-5213
Practice Address - Country:US
Practice Address - Phone:305-610-5328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL135542208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics